Provider Demographics
NPI:1205493145
Name:SURBAUGH, NICHOLE M (LMHCA)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:M
Last Name:SURBAUGH
Suffix:
Gender:F
Credentials:LMHCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2350 S STATE ROAD 1
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9698
Mailing Address - Country:US
Mailing Address - Phone:260-307-5030
Mailing Address - Fax:260-824-8445
Practice Address - Street 1:2350 S STATE ROAD 1
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:IN
Practice Address - Zip Code:46714-9698
Practice Address - Country:US
Practice Address - Phone:260-307-5030
Practice Address - Fax:260-824-8445
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88000477A101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor